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research focused on real treatment

Research Focused on Real Treatment

Presentation at “2007 National Association of Addiction Treatment Providers (NAATP) Conference”, May 20-23, 2007, San Diego, CA. The opinions are those of the authors and do not reflect official positions of the association or government. Available on line at www.chestnut.org/LI/Posters or by contacting Joan Unsicker at 720 West Chestnut, Bloomington, IL 61701, phone: (309) 827-6026, fax: (309) 829-4661, e-Mail: [email protected]

the panel
The Panel
  • Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center, Lighthouse Institute, Chestnut Health Systems, Bloomington, IL
  • Cara Renzelli, Ph.D., Director of Research and Evaluation, Gateway Rehabilitation Center, Pittsburgh, PA
  • Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents), Fairbanks , Indianapolis, IN
  • Valerie J. Slaymaker, Ph.D.,Director, Butler Center for Research, Hazelden, Center City, MN
  • Erin Deneke, Ph.D., Director of Research, Caron Treatment Centers, Wernersville, PA
  • Susan Gordon, Ph.D., Research Director, Seabrook House , Seabrook, NJ
what do we mean by research
What do we mean by research?
  • Management by objectives and milestones (budget, plans, internal funds)
  • Performance Monitoring (e.g, Oryx, NOMS, GPRA, internal and external funds)
  • Group problem solving to improve performance overal or for a subgroup (e.g, NIATX, Drug Courts)
  • Program Development and Evaluation (e.g., Private, state or CSAT grants)
  • Development and Replication of Evidenced Based Practices (e.g., CSAT, NIH grants)
  • Quasi-Experiments and Randomized Experiments (e.g, NIH grants)
as you move down this list
As you move down this list
  • It requires better and more consistent leadership, communications, and trust (particularly for a problem solving type approach)
  • Often requires patient or staff incentives as the burden goes up
  • Often requires building of infrastructure (workforce, equipment, systems) or changes in organizational culture that may take several years to be completed
  • The level of staff qualifications and experience goes up (typically from MA to Ph.D. with prior experience/grants)
  • The types of funding shifts (from direct service to state/foundation to CSAT to NIH)
  • The time to get funding gets longer and the likelihood of funding goes down (e.g., NIDA/NIAAA only fund the top 10-13% of applicants and that typically takes 1.5 to 2 years to get from the time the proposal is submitted)
  • May require collaboration with outside vendors (e.g. to help implement an evidenced based practice) or experts (e.g., in a specific analytic technique)
cara renzelli ph d director of research and evaluation gateway rehabilitation center
Cara Renzelli, Ph.D., Director of Research and Evaluation, Gateway Rehabilitation Center

Gateway Rehabilitation Center’s mission is to enable people affected by or at risk of addictive diseases and other mental and emotional disorders to lead healthy and productive lives through prevention, education, treatment, and research.

gateway s range of services
Gateway’s Range of Services
  • Genesis
    • Prevention
    • Evaluation
    • Detoxification
    • Inpatient
    • Outpatient
  • Extended Care
    • Halfway Houses
  • Corrections
  • Ohio – Neil Kennedy Recovery Clinic
research activities internal projects
Research Activities - Internal Projects
  • Study of detoxification medication
  • Exploration of gambling problems in our treatment population
  • Evaluation of teen leadership institute
  • Development and implementation of outcomes monitoring system
  • Assists on performance improvement initiatives
research activities external projects
Research Activities - External Projects

Gateway has long history of collaboration with

university-based research…recent endeavors include

  • 1980s & 1990s – Washington and Jefferson College and Indiana University of Pennsylvania: inpatient and outpatient treatment outcomes
  • 1992 – today – University of Pittsburgh Medical Center, WPIC: Pittsburgh Adolescent Alcohol Research Center
  • 2003 – 2005 – University of Pittsburgh, School of Social Work: study of adult outcomes and spirituality
  • 2006 – present – Washington University, School of Medicine: prescription abuse study
development and implementation of outcomes monitoring system
Development and Implementation of Outcomes Monitoring System
  • Need for outcome data (Why measure?)
  • Domains (What to measure?)
  • Time points (When to measure?)
  • Staffing needs (Who will measure and where?)
  • Practical applications (How will we use the data?)
outcomes monitoring system
Outcomes Monitoring System
  • Why we decided to create this system
  • Time points
    • Data collected on ALL patients at 1, 3, 6, 12, and 24 months after discharge from final level of care
    • Collected by phone, mail, or personal interview
  • Domains
    • Demographic – marital, employment, education
    • Criminal justice involvement
    • Additional post-discharge treatment
    • Relapse/abstinence
    • 12-step participation
    • Quality of life
outcomes monitoring system11
Outcomes Monitoring System
  • Staffing needs - Currently have one research director, one research assistant (RA), and a team of volunteers
    • All volunteers trained on basic research principles, data integrity, confidentiality
    • RA and volunteers collect data
    • RA manages collected data
  • Quiet, private space required
outcomes monitoring system12
Outcomes Monitoring System
  • Practical applications
    • Provides a picture of patients’ functioning after they leave our care
    • Allows us to look for trends in the data that alert us to investigate further or take action
    • Gives other departments within the Gateway system information that may meet a general or specific need
future directions of the research department
Future Directions of the Research Department
  • Increase the number and breadth of our in-house research and evaluation studies
  • Expand outcomes system to begin assessments at admission, during treatment, and at discharge
  • Expansion of survey domains
  • Continue our work with university-affiliated researchers
  • Form collaborations with other treatment facilities to seek funding for multi-site projects
  • Extend dissemination efforts
sigurd zielke d min clinical specialist adolescents fairbanks
Sigurd Zielke, D.Min. Clinical Specialist (Adolescents)Fairbanks

Fairbanks is a nonprofit organization focused on recovery from alcohol and other drug problems, serving as a resource to improve the well-being of individuals, families and communities by offering hope and support through its programs and services.

objectives
Objectives
  • To construct empirically-informed models and generate methods to enhance adolescent treatment and recovery support
  • To create an evidence-informed mindset among our clinicians i.e., an evidence-informed clinical culture
  • To secure external partners for the measurement of models and methods generated
full range of adolescent services
Full Range of Adolescent Services
  • Discovery (education)
  • Detoxification
  • Rehabilitation
  • Residential
  • Transitional Living
  • Partial Hospitalization
  • Intensive Outpatient
  • Recovery Management I & II
  • Hope Academy (Recovery High School)
challenges to adolescent treatment recovery support
Challenges to Adolescent Treatment & Recovery Support
  • Historic application of adult models of treatment and recovery to adolescents
  • Recent recognition by health services researchers… “that adolescence is different from adulthood, and that the methods to identify, treat, and prevent illness need to be different” (Zucker, 2006)
  • Emergence of the new field of developmental psychopathology
  • Explosion of neurobehavioral research
  • Lack of coherent adolescent treatment and recovery support models that integrate 12-step recovery processes with recent neurobehavioral and developmental findings
  • Need for empirical study of updated models
research needs i e targets
Research Needs (i.e., Targets)
  • Need for grounded identification of adolescent treatment, relapse and recovery issues (affirmation of practitioner knowledge)
  • Need for extensive professional literature reviews
  • Need for rigorous theoretical research—resulting in grounded, empirically-informed models
  • Need to develop methodologies to enact models
  • Need for clinical staff to utilize models/methodologies
  • Need to establish “fidelity standards”
  • Need to secure academic partners to measure the efficacy of the models/methodologies generated
research response projects
Research Response: Projects
  • Grounded video study of student behavior; over 2000 classrooms in light of neurobehavioral literature
  • Focus group narrative analysis study of educators experiences with young students coming to school SI
  • Joint hospital and university 2 year professional study of the literature on SI children/youth, addiction brain studies, and pathway findings
  • A field-based action research study to enhance the school behavior of SI elementary students: grades one through five—test of preliminary models
  • Theoretical research---NBD White Paper (July 2007)
  • Generation and utilization of empirically-informed methods:

- 90 in 90: A Recovery Tool for School Success

- Node link mapping of student relapses

  • Establishing collaborations with academic/research partners
slide22
Creating An Evidence

-

Informed Clinical Culture for

The Treatment And Recovery Support of Adolescents

1.

Identify/target

2.

Conduct

8.

Share results:

clinical issues of

field/grounded study

publication &

persistent concern

of targeted concern

training

to discern patterns

of functioning

7.

Use data to affirm,

3.

Identify strong lines

amend, or disregard

empirical evidence

models/ practice

that address

targeted concerns

4.

Synthesize findings

6.

Conduct quality

5.

Use models to

of 2 and 3 into field

-

improvement and pilot

guide practice and

theory and models

studies with external

create tools

of practice

collaborators

Critical Cultural Elements

Identify

“curious”

clinicians

Keep multidisciplinary

Carve

-

Provide readings

out 1hr per week

Keep collegial

Tie to writing and training

valerie j slaymaker ph d director of hazelden s butler center for research bcr
Valerie J. Slaymaker, Ph.D., Director of Hazelden’s Butler Center for Research (BCR)

Dedicated to improving recovery from addiction by conducting clinical and institutional research, collaborating with other research centers, and communicating scientific findings.

bcr structure
BCR Structure
  • Two doctoral-level research staff
  • One FT research assistant (others as funded)
  • Data collections staff
bcr activities
BCR Activities
  • Institutional research and evaluation
  • Clinical research and collaboration
  • Consultation
  • Knowledge dissemination
institutional research evaluation
Institutional Research & Evaluation
  • Outcomes data collection & reporting
    • 1, 6, and 12 month follow-ups
    • Use and functional outcomes
  • Special populations and reports
    • BCBS
    • Methamphetamine Outcomes Study
    • Family Program
    • Scale development
clinical research collaboration
Clinical Research & Collaboration
  • Milestones of Recovery studies
  • Phone-based Case Management
  • Huss Research Chairs on Late Life Addiction
  • Youth, AA and Treatment Processes study
  • University of Minnesota Youth & Neuroimaging study
knowledge dissemination
Knowledge Dissemination
  • Research Update
  • Substance Abuse Research Forum
  • Dan Anderson Research Award
  • Conference presentations
  • Published manuscripts
range of services
Range of Services
  • Inpatient Care –
    • Men’s Primary
    • Women’s Primary
    • Adolescent
    • Relapse
    • Young Adult Male Program (YAMP)
  • Extended Care –
    • Men, Women, and Adolescents
  • Family Education Program
  • Center for Self-Development
  • Caron Outpatient Counseling
current research activities
Current Research Activities
  • Focused Continuing Care
    • In collaboration with Treatment Research Institute
  • Chronic Pain Study
    • In collaboration with University of Pennsylvania and Reading Hospital
    • Funded by NIDA
  • Chronic Pain sub-study
    • In collaboration with Reading Hospital
  • Menstrual cycle and cravings study
  • Menopause and addiction study
caron research staffing
Caron Research Staffing
  • Director of Research –
    • Design , develop, coordinate, and implement intramural and extramural research projects.
    • Data analysis, reporting, publishing, and presentations
  • Research Administrator –
    • Participant recruitment and data collection
    • Data entry
    • Assist with literature reviews
  • Research Committee –
    • Review ongoing studies and outcomes
    • Evaluation of new or proposed projects – advantages/disadvantages both for internal as well as external studies
    • Act as an informal Human Subjects Review Board – all projects would be approved through committee for implementation at Caron.
  • Physician’s Advisory Committee –
    • Cutting edge treatment practices
    • Best research methodology
    • Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.; Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
focused continuing care
Focused Continuing Care
  • Available to all patients once leaving inpatient treatment
    • Adult only at this time
    • Will move to adolescent units
  • Monthly follow-up contacts by phone for 12 months by focused continuing care specialists (5)
    • Check in with patients to see how they are progressing in their recovery
    • Data collection on such variables as AA attendance, sponsorship, mental health issues, follow-up care, and family issues
  • Ability to analyze data at various points through 1 year post treatment
  • Outcome oriented
    • Both quantitative and qualitative data
  • Provide information on possible programmatic changes
  • Unit specific data
moving towards the future
Moving towards the Future
  • Increase the number of intramural projects occurring at Caron
  • Increase collaboration with other agencies and universities
  • Encourage more extramural research activities
  • Increase number of sources for outside funding of projects
  • Improve dissemination of information through published articles, conferences, presentations, and information available to consumers
  • Assist in marketing and public relation endeavors by providing media relevant information
susan gordon ph d director of research seabrook house
Susan Gordon, Ph.D., Director of Research, Seabrook House

“To help families find the courage to recover.”

seabrook research goals
Seabrook Research Goals
  • Process and outcomes evaluation of two residential treatment programs
  • Grant funding to increase/enhance clinical programs
  • Participation in NIDA CTN
seabrook evaluation project matriark family program
Seabrook Evaluation Project:MatriArk Family Program
  • Residential treatment facility
  • Low income women and children
  • 10 short-term (28 days) patients
  • 37 long-term (6 – 12 months) patients
  • 12-step treatment approach
  • Funded through state and local government
matriark goals
MatriArk Goals

In-treatment

  • Reunification of women with young children during treatment
  • Increase healthy pregnancies and births

Post-treatment

  • Increase abstinence
  • Increase 12-step participation
  • Increase bio-psycho-social functioning
matriark evaluation goals
MatriArk Evaluation Goals
  • Assess all eligible and willing patients
    • Admission and in-treatment
    • Discharge and one-year follow-up for treatment completers
  • Assess grant funding objectives
  • Identify strengths of the program
  • Identify aspects of the program to improve
matriark research infrastructure
MatriArk Research Infrastructure

PEOPLE: Staffing

  • Research Director
    • Develop & implement project
    • Analyze results
  • Research Assistant
    • In-treatment data collection and data entry
  • Aftercare Case Manager
    • Post-treatment data collection
    • Post-treatment needs assessment
matriark research infrastructure41
MatriArk Research Infrastructure

PLACES: Facilities

  • Private office space for patient interviews, follow-up calls

THINGS: Resources

  • Computer, network and internet
  • Locked filing cabinets
  • Separate telephone line and stationery for follow-ups
  • Appreciation gifts for patient follow-ups
matriark research infrastructure42
MatriArk Research Infrastructure

Protocols

  • Consent procedures
  • Post-treatment follow-up procedures
    • Locating difficult participants
  • Staff training and certification
    • Research ethics
    • Instrument administration
  • Safety protocol for home visits
matriark research infrastructure43
MatriArk Research Infrastructure

Oversight

  • Research and Education Advisory Committee
    • 10 SBH; 2 external members
    • Recommend research projects
    • Monitor ongoing research
  • No I.R.B.
    • Not Federally funded research
    • Not clinical trial
matriark assessments
MatriArk Assessments
  • Evidence-based assessments
    • Reliable and valid
    • Measure goals and objectives
  • Clinically-useful assessments
    • Applicable for treatment
  • Appropriate “response burden”
    • Main task of patients is treatment – not research!
michael dennis ph d director of the gain coordinating center chestnut health systems
Michael Dennis, Ph.D., Director of the GAIN Coordinating Center, Chestnut Health Systems

Improving the quality of human service interventions through applied research, publications, and training.

- Lighthouse Institute Mission

Improving assessment to facilitate evidence-based practices.

- GCC Mission

chestnut s direct clinical services
FY05 Admissions

1,000 to 9,999

100 to 999

10 to 99

1 to 9

Chestnut’sDirect Clinical Services

FY05 Admissions (n=9311) for Substance Abuse and Mental Health Services from 82 of Illinois 103 counties

chestnut s lighthouse institute research division
LI-Research

Facilities

Major Study

Geog. Areas

Chestnut’s Lighthouse Institute (Research Division)
  • Started in 1985 and grew to 90 full/part time staff grossing $9 Million a year in external funds (NIH, SAMHSA, Foundations)
  • LI-Research: Several major experiments, quasi-experiments and major surveys
  • LI-Training and Publications: 100s of training days and largest collection of evidence-based treatment manuals
  • EBTx Coordinating Center---Supports training, certification, and coaching of clinicians and clinical supervisors learning A-CRA and ACC
  • GAIN Coordinating Center – supports training, certification and use of the GAIN to support diagnosis, placement, treatment planning, and research
li s global appraisal of individual needs gain coordinating center gcc
`LI’s Global Appraisal of Individual Needs (GAIN) Coordinating Center (GCC)

NH

WA

VT

ME

MT

ND

MN

OR

MA

ID

NY

SD

WI

WY

MI

RI

PA

IA

CT

NE

OH

NJ

NV

DC

IL

IN

UT

CA

CO

WV

DE

MO

VA

KS

KY

DC

MD

NC

TN

OK

AZ

NM

AR

SC

0

1 to 10

GA

AL

MS

11 to 25

26 to 130

TX

LA

Statewide System*

AK

FL

HI

VI

PR

* Also being considered in FL, GA, NC, SC, TN

it took a lot of time to get here
It took a lot of time to get here…

Created GAIN Coordinating Center

Started going for External CSAT/ NIH Funding

Started by Bill White to do Training and Evaluation

multiple co occurring problems are correlated with severity and contribute to chronicity
Multiple Co-occurring Problems are Correlated with Severity and Contribute to Chronicity

Adolescents More likely to have externalizing disorders

100%

100%

40%

60%

80%

20%

20%

40%

60%

80%

0%

0%

Health Distress

Internal Disorders

Adults more likely to have internalizing disorders[

External Disorders

Crime/Violence

Criminal Justice

System

Involvement

Adults

Adolescents

Dependent (n=1221)

Dependent (n=3135)

Abuse/Other (n=385)

Abuse/Other (n=2617)

Source: GAIN Coordinating Center Data Set

slide54
Substance Use Careers are Longer,

the Younger the Age of First Use

100%

90%

21+

80%

Percent in Recovery

15-20*

Age of 1st Use Groups

70%

Years from first use to 1+ years abstinence

60%

under 15*

50%

40%

30%

20%

* p<.05 (different from 21+)

10%

0%

0

5

10

15

20

25

30

Source: Dennis et al 2005 (n=1,271)

slide55
Substance Use Careers are Shorter

the Sooner People get to Treatment

100%

0-9*

90%

80%

10-19*

Years to 1st Tx Groups

Percent in Recovery

70%

Years from first use to 1+ years abstinence

60%

50%

40%

20+

30%

20%

10%

* p<.05 (different from 20+)

0%

0

5

10

15

20

25

30

Source: Dennis et al 2005 (n=1,271)

slide56
It Takes Decades and

Multiple Episodes of Treatment

100%

90%

80%

Percent in Recovery

70%

Median duration of 9 years

(IQR: 3 to 23) and 3 to 4 episodes of care

Years from first Tx to 1+ years abstinence

60%

50%

40%

30%

20%

10%

0%

0

5

10

15

20

25

Source: Dennis et al 2005 (n=1,271)

slide57
1-3 Years:

Decrease in Illegal Activity; Increase in Psych Problems

5-8 Years:

Improved Psychological Status

3-5 Years:

Improved Vocational and Financial Status

1-12 Months:

Immediate increase in clean and sober friend

% of Clean and

Sober Friens

% Days of Illegal

Activity (of 30 days)

% Days Worked

For Pay (of 22)

% Days of Psych

Prob (of 30 days)

% Above

Poverty Line

Other Aspects of Recovery by Duration of Abstinence of 8 Years

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Using

1 to 12 ms

1 to 3 yrs

3 to 5 yrs

5 to 8 yrs

(N=661)

(N=232)

(N=127)

(N=65)

(N=77)

Source: Dennis, Foss & Scott (under review)

slide58
The Cyclical Course of Relapse, Incarceration,

Treatment and Recovery: Adults

P not the same in both directions

6%

7%

25%

30%

8%

13%

29%

4%

7%

44%

31%

8%

Treatment is the most likely path to recovery

Avg of 32% change status each quarter

Incarcerated

(37% stable)

In the

In Recovery

Community

(58% stable)

Using

(53% stable)

In Treatment

(21% stable)

Source: Scott et al 2005

rmc s impact on time to treatment re entry
100%

The size of the effect is growing every quarter

90%

80%

70%

630-246 = -384 days

60%

50%

40%

30%

20%

10%

0%

630

270

360

450

540

180

90

0

RMC’s Impact on Time to Treatment Re-Entry

Percent Readmitted 1+ Times

(n=221)

55% ERI-2 RMC*

37% ERI-2 OM

(n=224)

*Cohen's d=+0.41

Wilcoxon-Gehen

Statistic (df=1)

=16.56, p <.0001

Days to Re-Admission (from 3 month interview)

Source: Dennis & Scott, in press; Scott & Dennis, under review

rmc s impact on adult outcomes
Significant Increase in AbstinenceRMC’s Impact on Adult Outcomes

Months 4-24

Final Interview

100%

RMC

90%

OM

RMC Broke the Run

76%

76%

80%

Less Likely to be in Need of Treatment

68%

68%

70%

57%

60%

Less Symptoms

49%

Percentage

46%

50%

37%

40%

27%

30%

19%

20%

10%

0%

of 630 Days

of 7 Subsequent

of 90 Days

of 11 Sx of

Still in need

of Tx

Abstinent

Quarters in Need

Abstinent

Abuse/Dependence

(d=0.29)*

(d= -0.32) *

(d= 0.23)*

(d= -0.23)*

(d= -0.24) *

* p<.05

Source: Dennis & Scott, in press; Scott & Dennis, under review

contact information
Contact Information
  • Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center, Lighthouse Institute, Chestnut Health Systems

(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail: [email protected] , Web: www.chestnut.org/li)

  • Cara Renzelli, Ph.D., Director of Research and Evaluation, Gateway Rehabilitation Center

(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; E-mail: [email protected])

  • Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents), Fairbanks

(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail: [email protected] )

  • Valerie J. Slaymaker, Ph.D.,Director, Butler Center for Research, Hazelden

(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail: [email protected] )

  • Erin Deneke, Ph.D., Director of Research, Caron Treatment Centers

(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242, E-mail: [email protected])

  • Susan Gordon, Ph.D., Research Director, Seabrook House

(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail: [email protected] )

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